PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations

[Perioperative Pain Management in Children]

Acute pain therapy in children is highly complex. Already preoperatively, the course for a successful therapy is set in the interaction with the child and parents. The goal of the treatment is a satisfied child. This means the use of empathy and therapy planning aimed at a balance between effect and side effect and functionality. Modern concepts are opioid-sparing and procedure-specific. Regional anaesthesia plays a major role, among other things due to excellent safety data. Knowledge of age- and block-specific local anaesthetic dosages is essential. Little is known about pharmacodynamic data of analgesics in children. Although knowledge about pharmacokinetic characteristics is increasing, off-label use of analgesics is inevitable. International databases such as the Kinderformularium provide up-to-date information. When using opioids, rules for safe handling must be followed both in terms of use and prescribing. Non-opioids and adjuvants - individually or in combination - have an established place in perioperative pain management. Non-pharmacological interventions can reduce anxiety and pain. Anxiety is one of the risk factors for chronic postsurgical pain.

Evaluation of the Analgesia Nociception Index and videopupillometry to predict post-tonsillectomy morphine requirements in children: a single-centre, prospective interventional study

Background

Tonsil surgery causes significant and challenging postoperative pain. The Analgesia Nociception Index (ANI) and videopupillometry are two techniques of interest to monitor nociception in adults and may predict postoperative morphine requirements. We hypothesised that these techniques could predict the need for morphine after tonsillectomy in children. The main objective was to assess the prognostic significance of ANI and videopupillometry, measured at the end of surgery, on morphine consumption determined by a Face, Legs, Activity, Cry, Consolability (FLACC) scale score >3 in the Post Anesthesia Care Unit (PACU).

Methods

A single-centre, prospective, interventional study evaluating children between 2 and 7 yr old undergoing tonsil surgery was performed. ANI and videopupillometry with tetanic stimulation were measured under general anaesthesia 4 min after the end of the surgical procedure. Each child was evaluated every 10 min by a nurse using the FLACC scale in the PACU and blinded to the measurements performed in the operating theatre.

Results

Eighty-nine children were analysed and 39 (44%) received morphine in the PACU. Neither ANI values nor videopupillometry values were predictive of postoperative morphine consumption (areas under the receiver operating characteristic curve 0.54, 95% confidence interval [CI; 0.42-0.65], and P=0.57; and 0.52, 95% CI [0.41-0.63], and P=0.69, respectively). Neither ANI values nor videopupillometry values were correlated to the maximum FLACC scale score in the PACU with ρ=0.04 (P=0.71) and ρ=0.06 (P=0.57), respectively.

Conclusions

Neither ANI nor videopupillometry performed at the end of surgery can predict morphine consumption in the PACU in children undergoing tonsillectomy.

Acupuncture Analgesia in Patients with Postoperative Neck Pain: A Protocol for Systematic Review and Meta-Analysis

Background. There is a yearly increase in pain after neck surgery, which is accompanied by high consumption of opioids. However, the opioid addiction epidemic is one of the most serious public health problems worldwide. Therefore, it is important to find suitable alternatives for opioids. Acupuncture therapy has been found effective for some types of pain control. This protocol aims to evaluate the efficacy and safety of acupuncture therapy in the treatment of pain after neck surgery. Methods and Analysis. We will search eight electronic databases from their inception to April 2022. Only randomized controlled trials (RCTs) using manual acupuncture, auricular acupuncture, or electroacupuncture as major therapy will be included, regardless of whether the study was published in Chinese or English. The selection of studies and data extraction will be independently completed by at least two experienced reviewers with a master's degree. The methodological quality of the included studies will be assessed by the Cochrane risk-of-bias tool. For the meta-analysis, Review Manager Statistical (RevMan V.5.3) software will be used. The results will be presented as the risk ratio (RR) for the binary data and the mean difference (MD) or standardized mean difference (SMD) for the continuous data. Ethics and Dissemination. This protocol for a systematic review will be submitted to a peer-reviewed journal for publication and presented at a relevant conference, and there is no need to obtain formal ethical approval. Trial Registration Number. PROSPERO registration number CRD42021281722.

Clinical practice guidelines for pain management after tonsillectomy: Systematic quality appraisal using the AGREE II instrument

PURPOSE

We identified and appraised clinical practice guidelines (CPGs) for the management of post-tonsillectomy pain using the Appraisal of Guidelines for Research and Evaluation (AGREE II) guideline research tool.

MATERIALS AND METHODS

We conducted a literature search to identify CPGs addressing pain management after tonsillectomy. CPGs meeting inclusion criteria were then appraised by four independent reviewers in six areas of quality, as defined by AGREE II. Scaled domain scores were calculated for each quality domain. Intraclass correlation coefficients (ICC) were calculated in each domain to assess interrater reliability across guideline appraisals.

RESULTS

Nine guidelines meeting inclusion criteria were identified from a systematic search of the literature. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline detailing tonsillectomy and postoperative management in pediatric patients received the highest average score, with a mean of 90.1% in the six areas of quality. Three guidelines scored higher than >60% in five domains or more, defining 'high' quality per AGREE II: AAO-HNS, Scottish Intercollegiate Guides Network (SIGN), and Ontario Ministry of Health CPGs. The highest-scoring domain was domain 4: Clarity of presentation (87.4%) across guidelines, while the lowest scoring domain was domain 5: Applicability (49.4%). Variability in scaled domain scores between all CPGs was relatively consistent across domains, with a mean standard deviation of 22.4%. The average ICC calculated across all six domains was 0.78, indicating 'strong agreement' between reviewers regarding guideline quality.

CONCLUSION

Of the nine available guidelines detailing pain management following tonsillectomy we identified, only three (33%) were deemed 'high'-quality after appraisal using the AGREE II instrument, suggesting a need for development of novel, methodologically rigorous CPGs.

A randomized, double-blinded, placebo-controlled, single dose analgesic study of preoperative intravenous ibuprofen for tonsillectomy in children

PURPOSE

Tonsillectomy is a recognized treatment for children with tonsil hypertrophy and results in significant postoperative oropharyngeal pain. Fentanyl and other morphine-like analgesics are widely used as perioperative analgesia but are associated with side effects such as vomiting, nausea, and respiratory depression. As the least toxic non-steroidal anti-inflammatory drug, ibuprofen may be effective and safe for pain control after tonsillectomy. We aimed to explore whether the addition of intravenous (IV) ibuprofen administered at induction can reduce the need for early postoperativeanalgesics.

STUDY DESIGN AND METHODS

This randomized, double-blind, controlled clinical trial enrolled 95 pediatric patients who underwent tonsillectomy. Participants aged 6 months to 12 years were randomly assigned to either the experimental and control groups (1:1). The children were premedicated 15 min before surgery with IV ibuprofen 10 mg kg^-1 or placebo (normal saline). Pain was scored at 15, 30, and 120 min after extubation, and IV fentanyl (0.5 mcg kg^-1) was administered when the Faces, Legs, Activity, Cry, and Consolability (FLACC) Scale was ≥7 and deemed appropriate by the nursing staff in the post-anesthesia care unit (PACU). The visual analog scale was used as a supplementary evaluation for older children (≥7 years old) who were awake and could self-report pain. The primary outcome variable was the number of patients who received postoperative analgesia.

RESULTS

The requirement for rescue fentanyl was reduced by 18% with the addition of IV ibuprofen (P = 0.043). There were no signficant differences in the amount of fentanyl administered postoperatively (P = 0.127). Compared with the placebo group, the number of children who needed more than one dose of rescue fentanyl decreased in the experimental group, but the differences were not significant (P = 0.056). There were no significant differences between the groups in terms of operative blood loss (P = 0.978), vomiting, or postoperative bleeding (P = 0.474).

CONCLUSION

It is safe to administer IV ibuprofen 15 min before tonsillectomy, and it can significantly reduce the need for rescue fentanyl. IV ibuprofen should be considered as an important part of the multimodal approach for postoperative analgesia in children.

CLINICAL TRIAL REGISTRATION

Chictr.org.cn, identifier: ChiCTR2100044508.

Electric Insulating Irrigations Mitigates Esophageal Injury Caused by Button Battery Ingestion

OBJECTIVE

Accidental ingestion of button batteries (BB), usually occurred in children and infants, will rapidly erode the esophagus and result in severe complications, even death. It has been recommended that treatment of this emergent accident as soon as possible with drinking of pH-neutralizing viscous solutions such as honey and sucralfate before surgical removal can mitigate the esophageal injury. Recently, we reported that the electric insulating solutions such as edible oils could mitigate tissue damage in BB-exposed esophageal segments. In this study, we compared the protective effect of kitchen oil with honey or sucralfate, the recommended pH-neutralizing beverages, and with their mixture on esophageal injury caused by BB ingestion in pig esophageal segments and in living piglets.

METHODS

Effect of olive oil irrigations was compared to that of honey or sucralfate irrigations in the BB-damaged esophageal segments freshly collected from the local abattoir and in live Bama miniature piglets with the proximal esophagus exposed to BB for 60 min. Also, the effect of olive oil and honey mixture (MOH) irrigations was assessed in live animals. The BB voltage was recorded before insertion and after its removal. Gross and histological analysis of the esophageal injury was performed after BB exposure in segmented fresh esophagus and 7 days after BB exposure in live animals, respectively.

RESULTS

Olive oil irrigations demonstrated better protective effect against BB-induced esophageal damage, compared to honey or sucralfate for BB-induced esophageal damage in vitro. But in vivo study showed that olive oil alone exacerbated esophageal injury because all esophagi irrigated with olive oil perforated. Surprisingly, irrigations with the MOH showed considerable protective effect for BB-induced esophageal damage in live animals, significantly better than irrigations with honey alone. The MOH decreased BB discharge, reduced area of surface injury, attenuated injured depth of esophageal wall thickness, and downed the mucosal injury index in comparison to using honey alone.

CONCLUSION

Irrigations with olive oil alone couldn't prevent the BB discharge and is harmful for BB ingestion before surgical removal. However, mixed with honey, olive oil very effectively prevents the BB discharging and produces better esophageal protection than honey.

Electroacupuncture Alleviates Hyperalgesia by Regulating CB1 Receptor of Spinal Cord in Incisional Neck Pain Rats

Acupuncture therapy is effective in relieving postoperative pain of neck surgery, but its underlying mechanisms remain largely unknown. This study, in the incisional neck pain rat model, was designed to explore whether the endocannabinoid receptor 1 (CB1) in the cervical spinal cord is involved in the analgesic effect of electroacupuncture (EA) or not.The incisional neck pain model was established by making a longitudinal incision and applied EA treatment of Futu (LI18), Hegu-Neiguan (LI4-PC6), or Zusanli-Yanglingquan (ST36-GB34) for pain relief. The results showed that EA LI18 and EA LI4-PC6 effectively relieve allodynia caused by neck incision, which was obviously better than EA ST34-GB34 (P < 0.05). After EA, the expression levels of CB1 mRNA at 4h in the EALI18 group, and 24 and 48h in both EALI18 and EALI4-PC6 groups, and those of CB1 protein at 4, 24, and 48h in the EALI18 group, and the immunoactivity of CB1 in both EALI18 and EALI4-PC6 groups at 4h were significantly upregulated in contrast to those of the model group (P < 0.05). EA of either acupoint group had no effect on the expression of CB2 protein (P > 0.05). Moreover, the antinociceptive effect of EA was reversed by AM251 (CB1 antagonist). Immunofluorescence dual staining showed that CB1 expressed in astrocytes in the superficial layer (laminae I and II) of dorsal horns of the cervical spinal cord. Therefore, the findings of this study revealed that upregulation of CB1 expression in the cervical spinal cord contributes to the analgesic effect of EA in incisional neck pain rats. The CB1 receptor expresses on astrocytes.

Pain in children undergoing tonsillotomy with alternating ibuprofen and paracetamol - a prospective observational study

BACKGROUND

The optimal pain therapy for children undergoing tonsillotomy remains unknown. Our aim was to evaluate a standard pain therapy including the alternating application of ibuprofen and paracetamol.

METHODS

Pain intensity of 81 in-patients after tonsillotomy aged 2-12 years was evaluated three times daily (mean observation 3.85 days) using the Children's and Infants' Postoperative Pain Scale (CHIPPS) in children <5 years, or with the Faces Pain Scale-Revised (FPS-R) in older children. Parents completed the Parents' Postoperative Pain Measure (PPPM-D) in addition. Exceeding the cut-off value in one of the scores implied the indication for an opioid rescue medication (RM). Endpoints were number of children with indication for the RM, course of pain, concordance between pain scales, and adverse events.

RESULTS

Overall, 45.7% of children needed the RM either in the recovery room or on the ward. The rate of children having an indication for RM on the ward was 30.9%. The highest proportion of affected children was identified on the day of surgery (32.1%). Most indications were detected with the PPPM-D only. A comparison with an earlier study showed less affected children compared to ibuprofen monotherapy on the day of surgery and the first postoperative day. Eleven children (13.6%) developed fever.

CONCLUSION

Although our pain therapy concept was effective from postoperative day 1 onwards, it needs improvement for the day of surgery. The overall concordance between the PPPM-D and CHIPPS or FPS-R was low. Fever might be a confounder for the pain intensity measurement with the PPPM-D.